Transcription of REQUEST FOR REQUESTING ACTIVITY -Complete Items 1 …
1 12. REMARKS REQUESTING ACTIVITY -ADDRESSEE -Complete Items 1 through 10 (Except 8b); also complete Item 19. REQUESTING ACTIVITY WILL ENTER COMPLETE ADDRESS TO WHICH RECORDS OR FINAL REPLY SHOULD BE MAILED. Complete Items 8b, 11 to 14 or 15 to 18, as appropriate, final referrer shall return to requester. 9. REMARKS8. MIL VA a. RECORDS REQUESTED b. RECORDS FORWARDED MIL VA STATUS3. FEDERAL EMPLOYEE RECORDS CHECKED IN 8b FORWARDED. NO RECORDS FOUND FOR PATIENT DURING ABOVE PERIOD. MORE INFORMATION NEEDED. FURNISH FOLLOWING: 16. REMARKS REQUEST FOR MEDICAL/DENTAL RECORDS OR INFORMATION 4. TO (Include ZIP Code) 5. IDENTIFYING INFORMATION REPLY/REFERRAL REPLY/SECOND REFERRAL 19. RETURN TO: (Include ZIP Code) MILITARY VA BENEFICIARY DEPENDENT RECORDS CHECKED IN 8b FORWARDED. NO RECORDS FOUND FOR PATIENT DURING ABOVE PERIOD.
2 MORE INFORMATION NEEDED. FURNISH FOLLOWING: 3a. NAME OF SPONSOR (If dependent) OTHER (Specify) DATE 1. PATIENT (Last Name -First Name -Middle Name) 2. ORGANIZATION AND PLACE OF TREATMENT a. SERVICE NUMBER b. GRADE/RATE c. SOCIAL SECURITY ACCOUNT NO. d. VA CLAIM NUMBER e. DATE OF BIRTH (If Federal employee) 6. DATES OF TREATMENT (Inclusive) 7. DISEASE OR INJURY 10. SIGNATURE 11. TO: 13. SIGNATURE 14. DATE 15. TO: 17. SIGNATURE 18. DATE CLINICAL OTHERS (List under remarks) REPORT OF PHYSICAL EXAMINATION ALL AVAILABLE RECORDS (Except X-rays unless specifically requested) MEDICAL REPORT CARDS, EMERGENCY MEDICAL TAGS, FIELD MEDICAL CARDS ABSTRACT OF RATING SHEET HEALTH record DENTAL record X-RAY OUTPATIENT DD FORM 877, SEP 67 REPLACES EDITION OF 1 JAN. 60. USAPPC WHICH MAY BE USED.
